Case Study: The Crowded Clinic

Authors: Kate Ellis, M.D., Family Physician, Charles River Medical Associates Morana Lasic, M.D., Clinical Instructor in Anesthesia, Harvard Medical School and Brigham and Women's Hospital

You are one of the health care practitioners in a community health center that provides primary care to a multi-ethnic, multi-lingual urban community. Many, but not all, of the patients live below the poverty line. Physicians and nurses see a large volume of patients with challenging medical and psychosocial issues.

Lately you have realized that the scheduling of patient visits has become something of a nightmare. Because of the high volume of patients, the wait for an appointment for routine care can be anywhere from six to eight months or more. Even acutely ill patients often wait for two to three days to see a health care provider. Out of frustration, many patients are walking in without appointments, often during lunch hour or late in the afternoon when everyone is getting ready to leave.

What makes the problem so challenging is that 20 to 40 percent of patients fail to show up for appointments on a given day. Because of this high no-show rate, every other appointment on physicians' schedules is double-booked with the expectation that, out of the 30 to 35 scheduled patients, only 20 to 25 will actually show up. Occasionally, however, most of the patients do show up - and when a significant number of acutely ill patients also arrive, the work environment becomes unbearably chaotic for everyone.

Providers become harried and more likely to make mistakes, patients wait for long periods of time in crowded waiting rooms, and the atmosphere becomes increasingly hostile as the stress level mounts. It is clear that the quality and experience of health care for many of these patients is suffering partly because of a simple lack of access to care. And it is becoming increasingly clear also that the better-insured and English-speaking patients may be getting better access: they are more likely to get a timely appointment because they are more demanding of the system, and they are more likely to keep and show up for their appointments because of better communication. You are interested in finding a way to promote more equitable access to health care.

Case Analysis

The main problem that everyone is experiencing in this clinic is the high rate of noshows. It would be very easy to simply label the clinic's patients "non-compliant." But is it so? As health care providers, the burden is on us to find the most effective ways to serve our patient population. One possible approach to the problem at hand is to conduct a survey in an attempt to identify some specific reasons that may be contributing to such a high percentage of no-shows.

When patients are surveyed about their reasons for not coming to appointments, a few common reasons may emerge:

• A sick patient waited so long to be seen that she got better and didn't need the visit - or got worse and had to go to the emergency room.

• A patient did not have a phone, or his phone number changed, so he never received the reminder message the day before the appointment.

• A patient showed up for the appointment, but at the wrong date or time. He misunderstood because of a language barrier.

• A patient was afraid to take time off work and risk losing her job. It would have been much easier for her to make an evening or weekend appointment.

How to address this welter of concerns? You can begin by clearing away the backlog of appointments. One possible solution is a system called Open Access. This system allows patients to schedule appointments, even for routine well care, on the same day - usually with their own physicians. This approach has cascading benefits. For instance, if visits are scheduled on the same day, there's no need to make phone call reminders, eliminating the problem of patients' not having phones or not receiving the messages. Further, if patients can choose a convenient time to visit (including evening and weekend hours when they are more likely to be off from work), they eliminate the risk of losing their jobs.

There are a number of ways to get this clinic, currently swamped, to a point where it offers Open Access. This work is not easy and the transition period is often quite challenging. Physicians can provide more services during each visit (even if it means that the visits are somewhat longer), reducing the need for the patients to return. The staff can also spend a set period of time -- perhaps four to eight weeks - working through the backlog of patients and opening up the schedule for same-day appointments. This may lead to a significant patient overload, so there may be a need for overtime work and creative staffing until the backlog is cleared out (i.e. staff lunches may be staggered so that appointments are available at lunchtime). The hope is that patients will receive timely care, that they will be more likely to be seen by their own doctors instead of the most available physician, and that they will be more likely to avoid going to the emergency room for issues that can easily be handled in an outpatient clinic setting.

In addition to making appointment schedules more conducive to patient needs, other ways to serve patients better involve creating an environment more welcoming to the patients and more inclusive of the various cultures, languages, and issues of the various patient populations. There need to be some staff members who can speak the main languages of the patients and who are representative of the diversity of the patients.

There should be efforts to educate staff members about the various cultural beliefs of different patient populations. If patients perceive that they can trust the staff and be open with them, they are more likely to comply with the treatment regimens and to make follow-up appointments. Thus their medical problems are more likely to be successfully diagnosed and managed.

Discussion Questions

1. As mentioned above, one aspect of patient-centered care is fostering a culturally sensitive and diverse clinic  environment that makes patients feel more welcome. What are some ways in which this may be accomplished?

2. Read this article about Open Access. If you currently work in an office practice, how would your patients' experience change if what the author calls "advanced access" were implemented? How might advanced access change your experience as a patient?

3. In order to provide good care for a culturally diverse patient population, it is important to gain some understanding of their ways of being (their belief systems, their traditions, their feelings towards western medicine, etc.). Can you think of a particular patient population in your area that may have unique beliefs about health and illness that would be important to understand?

4. How well do you know your patients? Can you think of a patient population (a culture, ethnicity, religious group, sexual orientation) with which you do not have much familiarity? How might this lack of knowledge impact your care?

5. What are some ways in which you could be better educated in regards to the beliefs and traditions of the patient population in your area? How might that intervention benefit the patients?